The RN Utilization Management Specialist, under the direction of the Manager, Utilization Management serves a key role in coordinating the organization’s interdisciplinary effort to assess and effectively use organizational resources and to track and minimize the inappropriate use of such resources. 

COVID-19 and Flu Vaccination Requirement: It is required to be vaccinated for COVID-19 and Influenza. Exemption requests based on medical or religious reasons may be submitted, but must be approved for active employment. 

Why UnityPoint Health?

• Culture – At UnityPoint Health, you Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
• Benefits – Our competitive Total Rewards program offers benefits options like 401K match, paid time off and education assistance that align with your needs and priorities, no matter what life stage you’re in.
• Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
• Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.
• Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.

Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work. https://dayinthelife.unitypoint.org

Performs utilization management continued stay reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources.

• Maximizes positive financial outcomes for patients and hospital by conducting timely ongoing chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care.
• Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.
• Requests reviews with physician advisors, and/or Executive Health Resources (EHR), as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.
• Applies accepted potentially avoidable day logic to reviews so that accurate and timely data collection may occur.
• Proactively monitors insurance approval status in partnership with the Trinity UM Insurance Coordinator

Serves as a resource to internal and external staff on issues related to utilization management

• Maintains current knowledge of Utilization Review Methodology, software, criteria and regulations governing various payment systems.
• Maintains current knowledge of the Trinity Utilization Management Plan.
• Maintains current knowledge of CMS rules (e.g. Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.
• Coordinates and monitors appeals with outside organizations used for Second Level Review (e.g. EHR) as needed.
• Works with physicians regarding utilization issues as needed.
• Provides information to Denials staff as requested

Education:   Associates Degree or Diploma (RN) in Nursing. Bachelor’s Degree or higher preferred in nursing, business or related field, preferred.

Experience:  5+ years of nursing experience.  Experience in Utilization Management, case management, denials or managed care highly preferred. Management experience a plus

License(s)/Certification(s):  Registered Nurse – Licensed and registered in the states of Iowa and Illinois